30 January 2012 5:19 PM

Mitt Romney earns millions and he gives millions to charity. Sir Fred Goodwin takes millions for himself but risked and lost billions for us. Politicians stacked up debts of trillions for us to pay. Where's the morality in all this?

Archbishop Carey was absolutely right to defend welfare reform - morally right. It is wrong for hard work to be prized less than entitlement.

I believe that credit for the benefit system should go to taxpayers rather than to governments.

It is very odd that these home truths should ever need to be spelled out. But it appears that they do, both here and in the US.

Mitt Romney earned his money through skill and enterprise. That is commendable. He works in a competitive environment.

He then chooses to give to charity and he gets tax relief for doing so. A great many people benefit as a result.

He pays the tax that he is required to pay. The American system, in which investment income is taxed at a lower level than earned income, is morally highly questionable when rich people pay a smaller percentage of their income than poor people. But that is the American system, not some tax avoidance scheme particular to Mitt Romney.

He employs an accountant to ensure that he pays only the tax that he has to pay. That is prudent. Sir Fred Goodwin grabs what he can and he leaves a trail of destruction. That is unprincipled, rash and inconsiderate to others. Governments take money by force and under threat. They give it to their own pet projects and beneficiaries. Then they expect to be given the credit for doing so. That is immoral. It wasn't the government's money in the first place. Nor was it Sir Fred Goodwin's. But it is Mitt Romney's. He illustrates the true morality of Capitalism: earning and paying our own way. Sir Fred Goodwin illustrates the pitfalls of a mixed economy, in which the State bails out private failures. Government profligacy with other people's money is the hallmark of Statism. It is immoral. But each one of us needs to come clean over our own financial values and behaviour before we moralise over the behaviour of others. I earn my living. I pay my taxes. I employ an accountant. I give nothing to public charities but I support some chosen individuals. If I had money to invest I would ask Mitt Romney to invest it for me. I trust him financially because he knows the value and the morality of money. Generally, I would not trust governments to behave responsibly with my money. A government headed by Mitt Romney might just fit the bill. But, sadly, he is not standing for election in our country. If he were to be able to do so, I should like to see him attack the concept of a mixed economy. For the true morality of Capitalism to be seen in action, failing enterprises have to be allowed to fail rather than be propped up by those that are profitable. The minimum State should provide only for those who cannot support themselves. Responsibilities should take precedence over entitlement. That is a highly moral stance. The current alternative, in the mixed economy, is a pot pourri of graft, extortion, blackmail and nepotism. Our enterprising, decent, hard-working people - at all levels of our society - deserve better than that.

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27 January 2012 1:36 PM

Researchers in Oxford University Department of Public Health have found that deaths from heart attacks in the UK have halved in eight years. That is very much to the credit of the doctors and nurses working in the NHS.

Half the credit goes to NHS GPs for prescribing drugs to lower cholesterol levels in the blood. Also they helped patients to cut down their cigarette smoking and improve their diet and general health.

The other half of the credit goes to NHS hospital staff for improving coronary care and saving more lives after people have had heart attacks.

Each year in the UK 230,000 people suffer from heart attacks. The private sector has very little provision for acute care. Private GPs have negligible numerical influence.

Private hospital facilities and 24-hour staffing levels are generally inadequate for the provision of acute care. Also there is justifiable concern that bills will not be paid unless payment is made in advance.

So this immense burden falls mainly on the NHS. Their staff deserve full credit for this great achievement in clinical care.

One third of heart attacks are fatal. Prevention is the primary treatment for these patients. GPs are doing a good job. Patients must do their bit in looking after their health as best they can.

The cloud on the horizon in this respect is that people in their thirties and forties are fatter and less fit than their forbears. They are just coming into the age group of increased risk for heart attacks. They have to pay attention to these risks because otherwise the death rates will go back up again.

61 per cent of heart attacks are in men and 73 per cent are in people over 73 years old. The increase in retirement age means that these men either will not live that long or will not have the care-free retirement that they might otherwise enjoy.

The researchers and clinicians have given them good evidence and good advice. Now it's up to them to play their part.

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26 January 2012 11:12 AM

My father faded away in a nursing home. My mother, poor love, died in hospital with tubes in most body orifices. I want to go like Dad.

The Office for National Statistics records that one fifth of patients die at home but three quarters would prefer to do so. In Europe more patients die at home.

The Royal College of General Practitioners recommends that GPs should talk to seriously Ill patients about where they would like to die. Living wills' and 'End of life plans' should state, in the patients' records, whether they want to be given particular treatments or to be resuscitated.

Patients with whom 'anticipatory care plans' are made are three times more likely to die at home with Independence, dignity and a sense of personal control.

My mother was ninety three, deaf, blind and in pain. Her life, as she knew it and enjoyed it, was over. Repeatedly, she said 'Oh dear, oh dear'.

I asked the nursing home staff to give her appropriate pain relief and leave her to die. I was told 'We can't do that. We have to do what we can to keep her alive'.

I disagreed then and I disagree now. She had a wretched death in hospital after ten days of officious intervention.

She was dying, for heaven's sake. We all knew that. So did she. But nobody had the guts to say 'Let her go in peace'.

Perhaps the staff feared that they would be accused of failing to do all they could in medical care. I think it more likely that the doctors and nurses liked to prove to themselves that they were doing something positive.

But was that physical and mental distress positive? I think it was torture. With appropriate pain relief, she could have left this world gently, as my father did.

In the USA, which is even more litigiously minded than we are, eighty five percent of health care costs in the elderly are incurred in the last ten days of life. From fear of being sued, the doctors and nurses dare not let the patients die quietly.

The RCGP are right on this issue, even though it is their own members who will have more work to do as a result of these recommendations. They truly care what happens to their patients.

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24 January 2012 12:32 PM

Because of recent concerns over the reliability of breast implants used in cosmetic surgery, there is a move to ban advertisements for all cosmetic surgery.

My personal belief is that all doctors and clinics should be free to continue to advertise their services. But this belief comes with two major caveats. They should only be allowed to do so provided that they stay within the code of practice of the Advertising Standards Authority and they should be made to pay for the consequences of unreliability.

In my time as a private GP, I never advertised my services, other than in a brochure. I relied upon word of mouth for one patient referring another.

In my rehab centre, I spent quite a bit of money on advertising in the first five years of our existence but not after that. It didn't bring us any patients. It was a waste of money.

Nowadays my website is as far as I go in advertising my services. It simply provides information.

I don't suppose that my experience is substantially different from that of many other private specialists in my areas of clinical work. We could advertise but, after expensive and futile initial forays, most of us don't. We realise that there isn't much point.

Cosmetic surgeons are in a different category. There is no shortage of patients wanting these services privately when access to NHS services is not so straightforward. Private specialists and clinics providing cosmetic surgery can advertise and they do.

The concern comes over the possibility of emotionally vulnerable people being persuaded, as a result of claims in advertisements, to seek treatment with one clinic or specialist rather than another that might be better qualified and safer.

Although I understand that, I am as much concerned with the opposite prospect of a closed shop, in which the only choice is Hobson's.

Yet private patients, claiming the right to choose what they want, also have a responsibility to choose wisely. They might contemplate the Shakespearian observation that fault may lie largely in ourselves. These patients should consult their own doctors first of all.

In an ideal Utopian world, the NHS would supply all services free of charge to all patients on demand. But, cuts or no cuts, that cannot be done within a budget that would not bankrupt the entire country. The NHS cannot do everything for everybody. It never could and it never will.

While private practice is allowed at all, there will always be an opportunity for patients to choose to see private doctors if they can get a particular service at a time and place that they believe they would not get on the NHS.

And there will always be a market for some particular medical services. Cosmetic surgery is one of these.

People may want to change their appearance even when there is absolutely nothing wrong with them medically. Who is to say that they should not, or to prevent them from paying to do so?

Nips and tucks, implants,fillers and Botox - all as advertised - can be supplied but there should be warnings attached.

If patients react to an advertisement, rather than respond to the advice of a doctor, who will ensure that they are safe?

When patients asked me for a referral for a new nose or bust or whatever, I would refer them to surgeons I knew and trusted. Sometimes I would suggest that a referral would be unwise because the outcome might not be what the patient hoped for. The problem might have been more psychological than physical.

It is this caveat that might be lost if cosmetic surgery is undertaken by cowboys who know how to advertise their services but not how to perform them skilfully or with caution for the patients' emotional state.

Another serious concern is that, however excellent surgeons may be, they cannot do skilled work with shoddy goods. The recent faulty implants were the responsibility of the manufacturers.

They should have used quality materials and methods. Government regulators have the responsibility to check for quality and fitness for purpose.

How did the regulators allow these defective products to come on the market? This is the elephant in the room that nobody appears to be talking about while the surgeons and clinics are in the firing line.

But surely there is already sufficient protection in law. Patients can sue if they are dissatisfied. And they do. This right needs to be protected.

In the USA cosmetic surgeons sometimes get around litigation risks by advertising the fact that they do not carry insurance and that they have no personal financial assets. They say that it is therefore not worth suing them.

Maybe this is why, in that benighted country that is obsessed with appearances, cosmetic surgeons are sometimes shot dead by disappointed patients. This has also happened in the UK. We are scarcely less obsessed.

For these specialists their advertisements might be suicide notes.

If our private clinics and surgeons are not more self-disciplined and self-funding than they have been recently over the breast implant disaster, they need to watch out. Hell does know another fury such as a woman scorned - a man or woman mutilated.

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22 January 2012 5:26 PM

It's alright to be sad when distressing things happen. This feeling may need acceptance rather than treatment.

Vast numbers of people take antidepressants. Some of these people may be trapping themselves in a dependency. There are better ways of dealing with disturbing events and the feelings associated with them.

Consider this basic truth: no person and no event can make us feel sad. We feel sad when events are in conflict with our values.

If we had different values, our feelings in response to a previously disturbing or exhilarating event would change.

When my little dog died I felt very sad because I loved her. She was fun to have around. Had I not loved her, I would not have felt so sad. The event would have been the same but my reaction, my feelings, would have been different.

I loved working as a GP. I was sad when I stopped. I missed my patients, many of whom I had looked after for decades, and I missed the work itself. But what was initially a negative feeling is now a positive one.

I loved putting new ideas, that were well researched but non-conformist, into practice.Nowadays clinical work is more top/down directed than ever before.

Doctors have to do what they are told. They are no longer able to innovate. In the state sector or in the private sector, they are mere units of provision in the Grand Plans of government.

I don't want to be that sort of doctor. It doesn't fit with my values. My career as a GP is therefore over and I don't regret it.

Nowadays I work as a counsellor, my type of counsellor, and I'm very happy doing this work.

In all my work, I have never feared controversy. I am not saddened by it. I relish it. I learn new ideas when people challenge my existing beliefs.

My opponents, people who disagree with me, are therefore my friends. I learn from them and I stay fresh in mind and young in spirit.

I do not value security at the price of conformity. I am not saddened or frightened by insecurity. I value individuality. Otherwise I would be just a number.

Monty Python's Brian called out to the multitude, 'You're all individuals'. A lone voice responded, 'I'm not'.

Wonderful! The virtue of individualism could not have been expressed better.

So, when distressing events occur, we have a choice. We don't have to feel sad. We can accept that life just goes that way sometimes.

Or, by contrast, we can allow ourselves to feel sad because that is being true to ourselves.

Either way, we obviously need to follow the advice of our doctors but we don't necessarily need treatment of any kind. We need to remember, above all, what Monty Python taught us so whimsically, "Always look on the bright side of life".

That principle certainly worked for me, after the initial numbness had passed, in the distress of my recent years. It was a choice of behaviour and I took it.

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19 January 2012 2:18 PM

When medical practice was a calling we expected to be called out at nights and weekends. The doctors' Trade Union, the British Medical Association, put paid to that.

For the sixteen years in which I worked full time in the NHS, my wife knew full well that she was wedded to my telephone as well as to me. She also worked as an unpaid secretary because GPs were not given any allowance for employing our own wives or husbands.

All that changed in 2004 when a new contract, negotiated with the Labour government, enabled GPs to delegate 'out of hours' work.

The hope was that family doctors would commit themselves to improving the services they supplied during a standard working week.

Their hospital counterparts were restricted by European directives to limit their working hours to the same extent.

From that moment on, Medicine ceased to be a vocation or even a profession. It became just another job.

One result can be seen today in the acknowledgement by Harmoni, the deputising service that provides out of hours cover for nine million patients, that they use an increasing number of nurses to assess the significance of telephone requests by patients.

Meanwhile, the doctors themselves are pestered by pen-pushers. They thrash around in an engulfing sea of paperwork.

But are nurses safe to do the assessments that doctors themselves used to do? I give my own personal experience.

Last year I suddenly developed severe pain in my lower back. I could walk only a few yards without pain. I could sit or lie but not stand for more than five minutes. I could not even carry the weight of my laptop or a shopping bag.

I went to an Accident and Emergency department and was seen by a nurse who diagnosed a disc problem and recommended Paracetamol.

I went to another hospital and was seen by another nurse who gave me an appointment to see an orthopaedic specialist team. Ten days later I was seen by a physiotherapist.

He arranged for a scan and only then, when it showed an acute collapse fracture of a lumbar vertebra, was I first seen by a doctor.

I had seen two nurses, each of whom had been very kind but neither had the authority to arrange the appropriate test.

I am not impressed with a system that delegates clinical responsibility to people unable to take it.

If this is what happens when a patient, known to be a doctor himself, is seen in the flesh, what would be the likely result of a telephone consultation?

In my time in the NHS, I employed a nurse who I sent to America at my own expense to learn about Nurse Practitioners. She learned well and I then got her to see some patients alongside me and subsequently undertake monitoring of their further care I believe she was the first Nurse Practitioner in the UK. I told the Senior Nurse in The Department of Health because I thought this idea could be expanded.

She visited my practice and told my nurse that she should become a Health Visitor because otherwise she would have no career development.

She did exactly that. I lost my Nurse Practitioner and my idea lay in tatters until the NHS wanted to save money by getting nurses to do the work of doctors.

My recent experience shows me that they are not best placed to do that.

So what now? My guess is that the situation will get worse rather than better. Nurses will do even more work that should be done by doctors and nobody will do the work that should be done by nurses.

The doctors' Trade Union may be happy about that. The nurses' Trade Union may also be happy about that. I'm not - but I'm only a patient.

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17 January 2012 5:51 PM

Undercover reporters from the consumer magazine 'Which?' found that only one out of fifteen nutritionists gave advice that was accurate and safe.

The recommendations of six were rated as 'dangerous' and eight were said to 'fail'. Even the solitary success scored a 'borderline pass'.

That surprised me because the two nutritionists I know personally seem to me to be excellent.

I have never been a fan of 'Which?' it strikes me as being over impressed with its own virtue. However, we cannot ignore this piece of investigative journalism.

It is dreadfully arrogant and dangerous when a 'cancer sufferer' is told to delay medical treatment because nutritional therapy could cure.

Nor can we simply shrug when someone complaining of severe tiredness is told that nutritional therapy would initially make the symptoms worse and that this would prove that it was working.

When that same 'patient' is told not to contact a GP because the doctor 'wouldn't understand', the dangerous bias is clear in that particular case.

As a GP, I would refer patients to nutritionists when they had Crohn's disease or Ulcerative Colitis and other bowel disorders, but only after they had been carefully diagnosed and treated by medical specialists.

I would often investigate the possibility of food allergies, even though the standard RAST blood tests were known to be questionable in their accuracy.

Gluten sensitivity, leading to Coeliac disease, needs to be accurately diagnosed and treated so that lives can be saved. Lactose intolerance is equally well understood. Nut allergies can be fatal. There is a serious subject here, not one for idiots.

But, where vitamin and trace element deficiencies are concerned, there often appears to be more self-delusion and superstition than science.

I would generally recommend all patients to eat lots of fruit and vegetables and cut down on red meat, sugar and white flour. There is medical evidence that dietary advice such as this can be beneficial.

Irritable Bowel Syndrome presents a difficult clinical challenge because it is not a clear cut clinical condition. Physical and emotional symptoms are intertwined. The treatment can be paradoxical, with benefit sometimes coming from doing the opposite of what might be thought to be sensible or even obvious.

But beyond that, except for some clearly defined medical conditions, nutritional therapy can be obsessive, dangerous and frankly nuts.

One condition that tends to collect nutritionists like wasps to jam is anorexia. In my experience of treating fifteen hundred eating disorder patients, the sufferers themselves often wanted to become nutritionists. People who were food obsessed wanted to help others to be more food obsessed than they already were.

Clearly there are sensible things that we can do to change our eating habits in order to improve our health. But the 'Which' survey shows that we need to be very careful when we ask for help.

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15 January 2012 5:45 PM

We cannot trust medical research when thirteen percent of doctors and researchers based in Britain have observed others cooking the books.

The British Medical Journal, to its great credit, reports that alteration or fabrication of research data is common.

There is increasing concern that data on the outcome of clinical trials is being changed in order to win funding. Inevitably this puts patients at risk.

The UK Research Integrity Office exists but it has no powers.

The director-general of Research and Development and Chief Scientific Advisor at The Department of Health says that they do not support the creation of a new regulator. She says that responsibility should remain with the employers of doctors and researchers.

The General Medical Council does not appear to make this issue a major priority.

If medical research is as unreliable as this, journalists cannot write accurately and doctors cannot advise responsibly.

This Augean stable has got to be cleaned out. Passing the parcel of responsibility is not good enough.

The Department of Health and The General Medical Council should be proactive in getting rid of this scourge on the integrity of British Medicine.

But let's look at where it all begins. Junior doctors and researchers are under immense pressure to publish research in order to fill out their cvs. This enables them to move up the professional ladder and, in due course, to attract funds for further research.

Senior doctors and researchers are under immense pressure to prove that their departments are at the cutting edge of progress so that they will be able to attract funds for further research.

From bottom to top the system is almost designed to reward fraud and chicanery.

And where does the money come from? The hands of the funders may not be entirely clean.

If the State pays the bill, it might have a political agenda of its own.

Doctors working for the State may have a political agenda and want to show that their particular geographical area, or clinical speciality, is particularly in need.

The pharmaceutical industry may have a financial and clinical agenda, wanting to show that their drugs are effective. Otherwise they would get no profit and no return on their investment.

When the pharmaceutical companies provide the funds for post-graduate lectures, are they doing so out of the kindness of their hearts?

When they sponsor professorships, are they behaving totally altruistically?

Would the recipients of this largesse risk their own funding by reporting negative findings?

How would the pharmaceutical companies react if they did?

The answer to this last question, in one particular case, has recently been dragged out through the courts.

Altogether, this is an unhappy saga. The Editor of the BMJ should walk tall with pride in bringing this issue to wider attention.

Now let's see who has the guts to join her in this worthy cause. And who will crawl away, back under a stone.

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13 January 2012 9:24 AM

Meryl Streep may not be Margaret Thatcher but that's not the point. The film is gentle and yet forceful, tender and yet fierce, human and yet dispassionate.

It is remarkable how divisive even the film has been. It plays to packed houses in the south while being picketed in the north.

Lady Thatcher's friends won't see it because it is a travesty. Her enemies won't see it because they don't want anything to do with her. They both miss out on a great film.

The young Margaret and Dennis are as convincing as their mature counterparts. The film characters hold true, whether or not they are true to life.

The politician shows her mettle from start to finish. Eventually too much so, as illustrated in the film.

There is nothing obviously sanitised or demonised in this portrayal.

The disintegration of a magnificent mind, whatever use she may have made of it, is tragic. That, surely, is what the film is really about.

I am neither a politician nor a film critic but I have been a doctor all my adult life. I have seen minds fall apart at the seams. The reality in others, and the prospect in myself, terrifies me. Lady Thatcher's own word 'frit' would be a fearful understatement.

'The Iron Lady' is truly disturbing and has as disciplined a script as befits the subject. It is in a different league from the Hollywood version of 'The girl with the dragon tattoo', which is crude and sloppy.

This is Hollywood at its best. Whether or not it is a precisely accurate portrayal of Margaret Roberts/Thatcher is irrelevant. There could be no such film.

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12 January 2012 11:51 AM

It can also be a compulsive behaviour. That should be treated so that it doesn't reoccur.

Antony Worrall Thompson, the celebrity chef caught stealing from Tesco's, says that he has been under stress. Well he would, wouldn't he?

He says that he has recently moved home, attended the funerals of two friends, drives for two hours each day, has given up smoking, has been anaemic and works a twelve hour day.

But he says that he does not want to blame his criminal behaviour on stress. Then why did he tell us about it?

He also said that there had been massive trauma in his life and that he was abused as a child. But he didn't want to blame that either. So why did he give us all that psychobabble as well?

Many people have been abused or abandoned in childhood, or had fearfully traumatic lives, yet they did not go on to shop-lift or do any other compulsive act.

If he really wants to get better from his compulsive behaviour, he needs to cut the crap.

He needs to acknowledge, as he has done, that what he did was wrong. He also needs to accept, as he has done, that he did something 'without rhyme or reason'.

But there is a lot more to it than that. If he wants to be rid of this devastating compulsion, he needs to stop looking for rationalisations.

There are none.

He did something completely irrational. That is true for all of us who have addictive or compulsive natures. We cannot be helped by fishing around for justifications or explanations.

It may be true for him: he may be an addict of one kind or another. He may be one of us.

If so, he is in for a rocky ride. He needs to get off the pity pot and ask for guidance from people who have been in similar dreadful messes.

Compulsive behaviour is not helped through rational approaches, such as Cognitive Behavioural Therapy. It could not be. If our behaviour is insane, it means that our rational mind isn't working.

Acknowledging that is the first step on our road to long-term recovery.

Taking medications, such as so-called antidepressants, medicalises our problem and therefore takes us further away from a personal solution. It also clouds, rather than clears, our minds. It gives us false perceptions, based upon chemical interference with the natural processes of the brain.

The truth is tough, for those of us who are addicts of one kind or another, if we want to get well. That's the way it is. We have to be man or woman enough, humble enough, to see that we will not be able to help ourselves through determination and willpower.

Incidentally, shopping and spending compulsively and shop-lifting other than for hedonistic reasons, are commonly associated with eating disorders.

If Antony Worrall Thompson does have this particular aspect of addictive behaviour, he will not be the first celebrity chef to do so.

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DR ROBERT LEFEVER

Dr Robert Lefever established the very first addiction treatment centre in the UK that offered rehabilitation to eating disorder patients, as well as to those with alcohol or drug problems. He was also the first to treat compulsive gambling, nicotine addiction and workaholism.
He identified 'Compulsive Helping', when people do too much for others and too little for themselves, as an addictive behaviour and he pioneered its treatment.
He has worked with over 5,000 addicts and their families in the last 25 years and, until recently, ran a busy private medical practice in South Kensington.
He has written twenty six books on various aspects of depressive illness and addictive behaviour.
He now provides intensive private one-to-one care for individuals and their families.

He has written twenty six books on various aspects of depressive illness and addictive behaviour.

He now uses his considerable experience to provide intensive private one-to-one care for individuals and their families.